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Match Day 2003

Medical care regardless of insurance
- our obligation under EMTALA -

by: LAWRENCE M. SHUER

As acronyms go, EMTALA isn't the easiest to remember or pronounce, but it represents an important federal law that we must be familiar with and comply with.

Passed in 1986, EMTALA stands for the Emergency Medical Treatment and Active Labor Act. It is commonly known as the "patient anti-dumping law." Its original intent was to prohibit hospitals from turning away emergency patients, or other patients transferred to the hospital, simply because the patient was uninsured or otherwise lacked the means to pay for his/her care. As the law's name suggests, it was also designed to stop hospitals from transferring women in active labor to county hospitals because they could not cover the cost of their hospitalization.

EMTALA covers all emergency room patients regardless of their economic or insurance status. It states that hospitals have a duty to provide emergency care to anyone who needs it as a condition of serving the Medicare program.

The law requires that patients be evaluated through an appropriate medical screening exam without inquiring about their insurance status. If the patient has an emergency medical condition, he/she must be monitored and treated until he/she can be discharged without significant risk. Or, if the initial hospital does not have the capability to treat the patient, he/she must be safely and appropriately transferred to another hospital.

As an academic medical center, we are often asked to accept emergency patients from other hospitals that lack the specialists or services to evaluate and stabilize the patient. EMTALA mandates that we must accept a transfer of an unstabilized patient from another emergency department if we have the capacity to care for the patient and if he/she requires a higher level of care than provided at the initial hospital. Our obligation to accept the patient remains even if there are closer facilities with the same capabilities as our hospital.

The evaluation of the patient's condition and the decision to transfer an unstable patient rests with the transferring physician who has personally evaluated the patient.

Accepting such a patient is a two-step process. First, a receiving physician must accept the patient, and second, the receiving hospital must verify that it has the capacity to admit him/her. Capacity is determined by bed and service availability as well as staffing. We cannot refuse the patient on the grounds that the hospital is "full" unless every licensed bed in the building is, in fact, occupied.

Before refusing an ED transfer, the receiving physician should confer with others so the decision does not rest on his/her shoulders alone. Instead, the physician should first contact the administrative nursing supervisor to get information about bed availability and staffing. He/she should then confer with critical-care specialists Norm Rizk or Steve Ruoss before making a final decision.

That said, if after accepting the patient we find that the patient's condition was not accurately represented by the transferring hospital and we suspect that he/she was "dumped" by the other hospital - or if we ever suspect that our own hospital has violated EMTALA - we must report this to the state's Department of Health Services within 72 hours. If you think such a violation may have occurred, please contact the Risk Management Office immediately.

The penalties for violating EMTALA are potentially quite severe for the institution and the physician involved. The hospital may be excluded from the Medicare program and may be fined up to $50,000 per violation. Although less common, the physician may also be fined for failing to comply with EMTALA.

To aid our physicians and to ensure compliance with EMTALA, we have asked the SHC transfer center to involve Steve Ruoss or Norm Rizk in a dialogue with physicians before refusing to accept a transfer from an outside Emergency Department. If you have any questions about our EMTALA obligations, please contact me at lshuer@stanford.edu.